Healthcare Provider Details

I. General information

NPI: 1750881777
Provider Name (Legal Business Name): CELESTE THI LE RN, RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2018
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W SQUANTUM ST
QUINCY MA
02171-2122
US

IV. Provider business mailing address

110 W SQUANTUM ST
QUINCY MA
02171-2122
US

V. Phone/Fax

Practice location:
  • Phone: 617-376-3000
  • Fax:
Mailing address:
  • Phone: 617-376-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN2276190
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4519
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: